Provider Demographics
NPI:1528220209
Name:BRACKEN, JESSICA NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:NICOLE
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:717 N 190TH PLZ
Practice Address - Street 2:STE. # 1100
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-3913
Practice Address - Country:US
Practice Address - Phone:402-815-1700
Practice Address - Fax:402-815-1045
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9171207V00000X
NE26352207V00000X
IA40230207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026211300Medicaid
NE10026301600Medicaid
IA1528220209Medicaid
NE47068731799Medicaid
NE10026211300Medicaid
IA1528220209Medicaid
NE099099144Medicare PIN